Development and validation of an instrument to predict prolonged length of stay in the postanesthesia care unit following ambulatory surgery.

PURPOSE: We sought to develop and validate an Anticipated Surveillance Requirement Prediction Instrument (ASRI) for prediction of prolonged postanesthesia care unit length of stay (PACU-LOS, more than four hours) after ambulatory surgery. METHODS: We analyzed hospital registry data from patients who received anesthesia care in ambulatory surgery centres (ASCs) of university-affiliated hospital networks in New York, USA (development and internal validation cohort [n = 183,711]) and Massachusetts, USA (validation cohort [n = 148,105]). We used stepwise backwards elimination to create ASRI. RESULTS: The model showed discriminatory ability in the development, internal, and external validation cohorts with areas under the receiver operating characteristic curve of 0.82 (95% confidence interval [CI], 0.82 to 0.83), 0.82 (95% CI, 0.81 to 0.83), and 0.80 (95% CI, 0.79 to 0.80), respectively. In cases started in the afternoon, ASRI scores ≥ 43 had a total predicted risk for PACU stay past 8 p.m. of 32% (95% CI, 31.1 to 33.3) vs 8% (95% CI, 7.9 to 8.5) compared with low score values (P-for-interaction < 0.001), which translated to a higher direct PACU cost of care of USD 207 (95% CI, 194 to 2,019; model estimate, 1.68; 95% CI, 1.64 to 1.73; P < 0.001) The effects of using the ASRI score on PACU use efficiency were greater in a free-standing ASC with no limitations on PACU bed availability. CONCLUSION: We developed and validated a preoperative prediction tool for prolonged PACU-LOS after ambulatory surgery that can be used to guide scheduling in ambulatory surgery to optimize PACU use during normal work hours, particularly in settings without limitation of PACU bed availability.

RéSUMé: OBJECTIF: Nous avons cherché à mettre au point et à valider un Instrument de prédiction anticipée des besoins de surveillance pour anticiper toute prolongation de la durée de séjour en salle de réveil (plus de quatre heures) après chirurgie ambulatoire. MéTHODE: Nous avons analysé les données enregistrées dans le registre de l'hôpital des patient·es qui ont reçu des soins d'anesthésie dans des centres de chirurgie ambulatoire (CCA) des réseaux hospitaliers affiliés à une université à New York, aux États-Unis (cohorte de développement et de validation interne [n = 183 711]) et au Massachusetts, États-Unis (cohorte de validation [n = 148 105]). Nous avons utilisé un procédé d'élimination progressive régressive pour créer notre instrument de prédiction. RéSULTATS: Le modèle a montré une capacité discriminatoire dans les cohortes de développement, de validation interne et de validation externe, avec des surfaces sous la courbe de fonction d'efficacité de l'opérateur (ROC) de 0,82 (intervalle de confiance [IC] à 95 %, 0,82 à 0,83), 0,82 (IC 95 %, 0,81 à 0,83), et 0,80 (IC 95 %, 0,79 à 0,80), respectivement. Dans les cas commencés en après-midi, les scores sur notre instrument de prédiction ≥ 43 montraient un risque total prédit de séjour en salle de réveil après 20 h de 32 % (IC 95 %, 31,1 à 33,3) vs 8 % (IC 95 %, 7,9 à 8,5) comparativement aux valeurs de score faibles (P-pour-interaction < 0,001), ce qui s'est traduit par une augmentation de 207 USD du coût direct des soins en salle de réveil (IC 95 %, 194 à 2019; estimation du modèle, 1,68; IC 95 %, 1,64 à 1,73; P < 0,001). Les effets de l'utilisation du score de notre instrument de prédiction sur l'efficacité d'utilisation de la salle de réveil étaient plus importants dans un CCA autonome sans limitation dans la disponibilité des lits en salle de réveil. CONCLUSION: Nous avons mis au point et validé un outil de prédiction préopératoire de la prolongation de la durée de séjour en salle de réveil après une chirurgie ambulatoire qui peut être utilisé pour guider la planification en chirurgie ambulatoire afin d'optimiser l'utilisation de la salle de réveil pendant les heures normales de travail, en particulier dans les milieux sans limitation de disponibilité des lits en salle de réveil.

Predictors of mortality in chronic subdural hematoma evacuation.

Chronic subdural hematoma (cSDH) is one of the most common types of intracranial hemorrhages, particularly in the elderly. Despite extensive research regarding cSDH diagnosis and treatment, there is conflicting data on predictors of postoperative mortality (POM). We conducted a large retrospective review of patients who underwent a cSDH evacuation at a single urban institution between 2015 and 2022. Data were collected from the electronic medical record on prior comorbidities, anticoagulation use, mental status on presentation, preoperative labs, and preoperative/postoperative imaging parameters. Univariate and multivariate analyses were conducted to analyze predictors of mortality. Mortality during admission for this cohort was 6.1%. Univariate analysis showed the mortality rate was higher in those presenting with a history of dialysis. In addition, those who presented with altered mental status, were intubated, and lower GCS scores had higher rates of POM. Usage of Coumadin was correlated with higher rates of POM. Examination of preoperative labs showed that patients who presented with anemia or thrombocytopenia had higher POM. Imaging data showed that cSDH volume and greatest dimension were correlated with higher rates of POM. Finally, patients that were not extubated postoperatively had higher rates of POM. Multivariate analysis showed that only altered mental status and being not being extubated postoperatively were correlated with a higher risk of mortality. In summation, we demonstrated that altered mental status and failure to extubate were independent predictors or mortality in cSDH evacuation. Interestingly, patient age was not a significant predictor of mortality.

Association of sugammadex reversal of neuromuscular block and postoperative length of stay in the ambulatory care facility: a multicentre hospital registry study.

BACKGROUND: Encapsulation of rocuronium or vecuronium with sugammadex can reverse neuromuscular block faster than neostigmine reversal. This pharmacodynamic profile might facilitate patient discharge after ambulatory surgery. METHODS: We included patients who underwent ambulatory surgery with general anaesthesia and neuromuscular block between 2016 and 2021 from hospital registries at two large academic healthcare networks in the USA. The primary outcome was postoperative length of stay in the ambulatory care facility (PLOS-ACF). We examined post hoc whether the type of reversal affects postoperative nausea and vomiting and direct hospital costs. RESULTS: Among the 29 316 patients included, 8945 (30.5%) received sugammadex and 20 371 (69.5%) received neostigmine for reversal. PLOS-ACF and costs were lower in patients who received sugammadex vs neostigmine (adjusted difference in PLOS-ACF: -9.5 min; 95% confidence interval [95% CI], -10.5 to -8.5 min; adjusted difference in direct hospital costs: -US$77; 95% CI, -$88 to -$66; respectively; P<0.001). The association was magnified in patients over age 65 yr, with ASA physical status >2 undergoing short procedures (<2 h) (adjusted difference in PLOS-ACF: -18.2 min; 95% CI, -23.8 to -12.4 min; adjusted difference in direct hospital costs: -$176; 95% CI, -$220 to -$128; P<0.001). Sugammadex use was associated with reduced postoperative nausea and vomiting (17.2% vs 19.6%, P<0.001), which mediated its effects on length of stay. CONCLUSIONS: Reversal with sugammadex compared with neostigmine was associated with a small decrease in postoperative length of stay in the ambulatory care unit. The effect was magnified in older and high-risk patients, and can be explained by reduced postoperative nausea and vomiting. Sugammadex reversal in ambulatory surgery may also help reduce cost of care.

Incidence and predictors of case cancellation within 24 h in patients scheduled for elective surgical procedures.

OBJECTIVE: Avoidable case cancellations within 24 h reduce operating room (OR) efficiency, add unnecessary costs, and may have physical and emotional consequences for patients and their families. We developed and validated a prediction tool that can be used to guide same day case cancellation reduction initiatives. DESIGN: Retrospective hospital registry study. SETTING: University-affiliated hospitals network (NY, USA). PATIENTS: 246,612 (1/2016-6/2021) and 58,662 (7/2021-6/2022) scheduled elective procedures were included in the development and validation cohort. MEASUREMENTS: Case cancellation within 24 h was defined as cancelling a surgical procedure within 24 h of the scheduled date and time. Our candidate predictors were defined a priori and included patient-, procedural-, and appointment-related factors. We created a prediction tool using backward stepwise logistic regression to predict case cancellation within 24 h. The model was subsequently recalibrated and validated in a cohort of patients who were recently scheduled for surgery. MAIN RESULTS: 8.6% and 8.7% scheduled procedures were cancelled within 24 h of the intended procedure in the development and validation cohort, respectively. The final weighted score contains 29 predictors. A cutoff value of 15 score points predicted a 10.3% case cancellation rate with a negative predictive value of 0.96, and a positive predictive value of 0.21. The prediction model showed good discrimination in the development and validation cohort with an area under the receiver operating characteristic curve (AUC) of 0.79 (95% confidence interval 0.79-0. 80) and an AUC of 0.73 (95% confidence interval 0.72-0.73), respectively. CONCLUSIONS: We present a validated preoperative prediction tool for case cancellation within 24 h of surgery. We utilize the instrument in our institution to identify patients with high risk of case cancellation. We describe a process for recalibration such that other institutions can also use the score to guide same day case cancellation reduction initiatives.